Posted on: April 20, 2012 Posted by: Comments: 0

Watching the movie Titanic, in younger years, I was caught up in the love and class triangle. Little did I know that my focus would change to the transport, safety and culture triangle.

The Titanic disaster is recognised as one of the iconic human failures in transport technology and culture, and it is incumbent on safety managers from all transport modes to take a leaf out of its thick book.

The centenary of 1912 to 2012 marking the sinking of Titanic should serve a thought provoking lesson for the railway industry, particularly in southern Africa, and for our approahces to risk assessment, change management, incident investigation, standards, regulations, human factor management, corporate culture, and industrial culture.

Incident investigation is a titanic labour and at times investigators make erroneous conclusions based on available facts. Early Titanic investigations were no exception.

Flawed culture, flawed investigation

The initial joint accident investigation between Britain and America concluded that the cause of the accident was confined to a glancing blow to the hull against an iceberg. The world believed in the findings of the investigation for 73 years, until it was discovered in 1985 that the ship broke into two pieces, three hours after the collision, due to icy waters attenuating the steel and rivets of the stupendous ‘unsinkable’ ship.

Should the findings emanating from accident investigations be treated as sacrosanct, or should we keep open minds? Given what happened to the Titanic, is it enough to have one team of investigators, or board of inquiry, or should we have parallel teams of investigators on major rail disasters, and reconcile their findings?

Many lessons, few students

Raymond Parsons said that “Tragedies and disasters usually teach valuable lessons, though they may not always have good students.” (Business Day, 11 April 2012). That industries do not learn from disasters is evident in recent oil, gas, coal mining, nuclear and other disasters.

People, and especially groups of people who share responsibility for learning, do not pay attention to disasters because they are ‘learning disabled’ by several cultural factors.

Disasters serve as a binding force to humanity. “Ask not for whom the bell tolls, it tolls for you.” Call the roll of human disasters: Titanic, wars, holocaust, sinking of the Philippine ferry, Rwandan genocide, Ladbroke train accident in London, Glenbrook train accident in Sydney, Haitian earthquake, heart wrenching Tsunamis and earthquakes in Indonesia and Japan.

All these tragedies are indelibly printed on human minds like a San Bushman painting, ineffaceable! More than 1500 people were drowned and only 705 survived after the Titanic hit the iceberg (see a list of African major disasters elsewhere on SHEQafrica.com).

Lifeboats is but one of hundreds of contributing factors to the disasters, including legislation, design changes, budget changes, schedule changes, rivet hammering method changes, schedule pressures, starlight refracting on calm water, complacency, radio priorities, warning fatigue, and chance.

The Titanic had 16 lifeboats and four collapsible boats. At full capacity, they could hold about 1170 people. But there were 2200 passengers and the crew on board.

The question of lifeboats is relevant to legislation and compliance. There were not enough lifeboats to cater for passengers and crew, yet Titanic carried enough lifeboats to comply with the law, plus four extra.

The British government had failed to update regulations to keep pace with rapid increases in the size of ships at the beginning of the century with its excesses of steel and steam. The government lamentably failed to account for how the economic environment impacted on public safety.

According to Awake! (2012)  approximately 900 000 immigrants entered the United States per year between 1900 and 1914, and Titanic was part of that economic shift.

Regulations should not be rigid, but move with technology. Changes in industry should trigger development of standards.

Wider, faster rail, requires new legislation

Rail technology in southern Africa compels us to move from narrow gauge to standard gauge, to accommodate high speed trains. It would be disastrous if we did not adjust our regulations to accommodate high speed rail in terms of speed limits and other train working rules.

One of the Titanic lessons for the Railway Safety Regulator is that regulations should not be cast in concrete, but should be adjusted to suit new realities.

Other lessons concern human factors, and here the RSR is among the pioneers of adopting and advocating assessment and management of human factors (see report on Railway Human Factor Standard elsewhere on SHEQafrica.com).

Titanic captain EJ Smith had reached the zenith of his career and was due to retire at the end of the voyage. He had sailed this route in the Olympic and he knew the hazards posed by ice in the North Atlantic (Awake!, 2012).

Several warnings of icebergs were sent by other ships, some were sent to the bridge, but the result was a small course adjustment. “A smaller ship, Californian, had stopped in the ice field nearby. Its crew saw distress rockets sent up by Titanic in the distance. But the captain did not grasp what they meant.” (Parson, 2012).

Although the captain had route knowledge, he was not trained in hazard identification and risk assessment (HIRA), and did not follow his own risk appetite. He was a merchant navy man who executed the risk appetite of his employers, and they wanted to make headlines by setting a trans Atlantic record.

Had Capt Smith been trained and practice in worse case scenarios, like airline pilots are, he may have chosen to hit the iceberg head, instead of damaging a long section of the hull by a last minute attempt to turn the ship away.

Capt Smith did not understand the dynamics of steering a large sheet, and he was mesmerised at the speed they were racing at. Train drivers should be trained in their relevant aspects of technology and behavioural psychology.

Transport paradigms should changed with technology, and simulators, as used by mining employers to skill up drivers of multi million rand plant, could work for rail too.

High speed trains require a higher level of training and risk management skill. The Titanic was one of the largest ships of its day, 269 meters long and 28 meters wide. A century old incident could teach us a lot today.

Managing in hindsight

A recommendation from a joint investigation between Britain and America (City Press, 8 April 2012) included:
• more lifeboats
• lifeboat drills better run
• communication equipment manned around the clock
• international Ice Patrol set up to monitor icebergs
• maritime safety regulations and procedures harmonised internationally.

These recommendations have stood the test of time and saved many lives, but they could not prevent disasters involving later technology, like sinking of the Philippines ferry 25 years ago, which drowned 4000 people, and some other transport disasters.

In rail, SPAD (Signals Passed at Danger) is an area of acute need. The rail industry should come together to devise ways and means of monitoring SPADs and to come up with recommendations to apply across the railway industry in the region.

The challenge for the railway industry is likewise international harmonisation, but there are also some ‘back at home’ legislative issues to sort out first.

Safety management is not static, but dynamic. It is tragic that we still commit many of the same mistakes that were committed in the past century.
Attitudes like ‘unsinkable’ and “100% safe” shortcut the culture of continuous risk awareness, risk assessment and event preparation that management and operators should practice. Complacent people are at greater risk.

Technology had never replaced human risk assessment, and is not likely to. Regulation, for its part, must not be coercive, but progressive, and not replace risk assessment, since it is a bare minimum and no guarantee that health and safety could be considered managed if we ‘comply’.

There are rules in safety, but there is no safety in rules.

• MABILA MATHEBULA IS A SENIOR RESEARCHER AT THE RAILWAY SAFETY REGULATOR (RSR). THE VIEWS EXPRESSED ARE HIS AND NOT THAT OF THE RSR.

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